Managing Managed Care

Our inequitable, inefficient, oftentimes uncaring health care "system," revealed. -- Jeffrey G. Kaplan, M.D., M.S.

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Cost-Sharing (Hi Deductible) "Health" Plans--Less $ and Prevention

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Patient or Guardian Responsibility in the Cost of Care Employers have been cost-sharing to mitigate the ever rising healthcare premium costs.  Examples: HMO's/PPO's now see annual deductibles in 83% of people in employer-sponsored coverage [up from 53% in 2006], co-insurance, co-pays and, more recently 'high-deductible' Health Plans (HDHP) [In 2016, 29% of covered employees were in an HDHP, up from 8% in 2008.] 

The Business Opportunity of Medicine

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The practice is getting squeezed; Want ideas? First, don't give up on the idea that small practices are out.  Consider them, if for no other reason then they are often better then large pracices that are overly driven to see large volumes of patients. IOW, solo and small practices are still playing an important role, although they may require TLC to thrive.

Rethinking Cancer

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Cancer; Just who invited you? Many cases of cancer are just caused by "bad luck" as two scientists "suggested in an article published last week in the journal Science. The bad luck comes in the form of random genetic mistakes, or mutations, that happen when healthy cells divide."  

Physician Compensation

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Reform will fail when practitioners are not getting paid for legitimate work they do. Paying healthcare practitioners fairly is the crux of healthcare payment reform.  Here is a brief synopsis of how methods to reign in physician compensation have always failed and nothing was ever solved through cost-shifting or cost-sharing. In brief, various attempts "Reforming Medicare's Physician Payment System" [N Eng J Med] have fallen flat.

Practices Must Change for Cost Effectiveness Research to Work

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It is unclear in the U.S. if Cost Effectiveness Research (CER) studies are compelling enough to overturn insurer's coverage decisions or reduce well-established procedures--Beware the status quo

Duh! Better Health Care Coverage--Better Health Care; Better Results

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Much of the work on health disparities and inequities in access focuses on comparisons between the insured and those without coverage. It should come as no surprise that the uninsured come out wanting and “Uninsurance is associated with mortality.”  Furthermore, Uninsured persons have less access to services, suffering worse health outcomes than that of the insured. Breast Cancer patients seem to have a 30-50% higher mortality rate then those without cancer.

Managed Care Organizations Practicing Medicine (Without a License)

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Aetna refused to pay for a visit of a child with a probable goiter and strong family history who needed diagnostic lab tests—they do not accept rule-outs.  Not long ago, Oxford levied a $50 deductible and $25 co-pay for the most efficacious eardrop we have in our armamentarium; Reason? This drop, containing an antibiotic and a steroid was not available generically; they were forcing me to use a plain ear drop – not what the doctor ordered! Mental Health Parity; Let the HMO's Be Damned!

Cutting health care and entitlement costs?!?

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We can sustain recent successes that increase the number of insured, improve the value of health care, reduce waste, and entitlement costs. [Ref.–the Accountable Care–Act (ACA)]. In addition, "healthcare costs can be controlled if we focus on and implement adequately risk-adjusted payment incentives* for a small number of outcomes. A small number of outcomes is critical for consumer understanding and will facilitate healthcare delivery change.

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